Summer Camp Scholarship Application

PLEASE FILL OUT THIS FORM COMPLETELY AND SUBMIT WITH THE REQUIRED ITEMS TO: Scholarship AdministratorDiscovery Place, Inc. Date of Application: ____________________________________________________________________________301 N Tryon Street SCHOLARSHIP APPLICATION DEADLINE: APRIL 15, 2014Charlotte, NC 28202Email: scholarships@discoveryplace.org

Summer Camp Scholarship Guidelines:• Applicants are evaluated without regard to race, religion, natural origin, sex or physical ability. • Funding is limited and scholarships are not guaranteed to all applicants. • Staff of Discovery Place, Inc. and their children are not eligible for scholarship assistance. • Scholarships may not be awarded two years in a row. • Incomplete applications will not be reviewed. • Scholarships will be awarded based on need and merit.

Summer Camp Scholarship Recipient Requirements:□ Submit completed application□ Submit financial documentation demonstrating need (if applicable, for need based)□ Submit letter of intent demonstrating passion for science and/or nature (if applicable, for merit based)□ Complete and submit follow-up report (attached) and/or letter after Summer Camp

Please fill out one form per child.

Name of Child_____________________________________________________________________________________________________________________________________________ Birth date_____________/_____________/_______________________

Mailing Address________________________________________________________________________________________________________________________________________________________________________________________________________________

City______________________________________________________________________________________________________________________________________________________________ State______________________ ZIP_______________________________

Phone (_________________) ____________________________________________________________ Family Email__________________________________________________________________________________________________________________________

Rising Grade_______________________________________________________________________ School___________________________________________________________________________________________________________________________________

Scholarship Type:□ Need□ Merit

If you are not selected to receive a Summer Camp scholarship, would you accept a Family Membership? □ Yes □ No

What do you hope your child will gain from this experience? _________________________________________________________________________________________________________________________________________

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What is your previous experience at Discovery Place, Charlotte Nature Museum and Discovery Place KIDS? ___________________________________________________________

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How many children currently live in the household? ____________________ Please list their ages: _______________________________________________________________________________________________

Do you currently have a Museum Membership? □ Yes □ No If yes, list Membership expiration date: _____________________________________________________________

Form continues on next page.

REQUIRED FAMILY INFORMATION

Father’s Name __________________________________________________________________________________________________________________________________________________________________________________________________________________

Address (if different) ________________________________________________________________________________________________________________________________________________________________________________________________________

Place of Employment________________________________________________________________________________________________________________________________________________________________________________________________________

Mother’s Name ________________________________________________________________________________________________________________________________________________________________________________________________________________

Address (if different) ________________________________________________________________________________________________________________________________________________________________________________________________________

Place of Employment________________________________________________________________________________________________________________________________________________________________________________________________________

Name of Legal Guardian (if not living with mother/father)_______________________________________________________________________________________________________________________________________________

FINANCIAL INFORMATION

Eligibility for need-based scholarships is based on the following criteria and conditions, including household size* and income standards. If an applicant does not fall within these criteria but can prove other special circumstances, the scholarship committee will review and may grant a scholarship.

*Household includes all people (adults and children) living in the household, related or not (grandparents, other relatives, friends, etc.).

Please indicate your total annual household income from all sources (including wages, interest income, investments, alimony, child support, social security, public assistance):

□ Below $10,000 □ $20,001-$25,000 □ $35,001-$40,000 □ $50,001 - $55,000

□ $10,001-$15,000 □ $25,001-$30,000 □ $40,001-$45,000 □ $55,001-$60,000

□ $15,001- $20,000 □ $30,001-$35,000 □ $45,001-$50,000 □ $65,001-$70,000

□ Over $70,000

Are there any extenuating circumstances, permanent or temporary, that make financial assistance necessary at this time? _______________________________________

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__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Are other family members currently applying for assistance? □ Yes □ No

Has anyone in your family previously received financial assistance through our scholarship fund? □ Yes □ No

If yes, when? ___________________________ How much was received? $_________________________________________________________

Fee Amount you are requesting: $_________________________________________________________

In addition to the fee, how much can you contribute? $_________________________________________________________

If you have any additional questions, please contact the scholarship administratorat scholarships@discoveryplace.org or 704.372.6261 x359.

Total Household Size* Yearly Income Monthly Income

2 $25,900 $2,159

3 $32,560 $2,714

4 $39,220 $3,269

5 $45,880 $3,824

6 $52,540 $4,379

7 $59,200 $4,934

8 $65,860 $5,489

Post-Summer Camp Report(Due 30 days after completion of Summer Camp)

PLEASE FILL OUT THIS FORM COMPLETELY AND SUBMIT WITH THE REQUIRED ITEMS TO: Scholarship AdministratorDiscovery Place, Inc.301 N Tryon StreetCharlotte, NC 28202Email: scholarships@discoveryplace.org

Name of Child_____________________________________________________________________________________________________________________________________________ Birth date_____________/_____________/_______________________

Mailing Address________________________________________________________________________________________________________________________________________________________________________________________________________________

City______________________________________________________________________________________________________________________________________________________________ State______________________ ZIP_______________________________

Phone (_________________) ____________________________________________________________ Family Email__________________________________________________________________________________________________________________________

Rising Grade_______________________________________________________________________ School___________________________________________________________________________________________________________________________________

Scholarship Type:□ Need□ Merit

Where did you attend Summer Camp?□ Discovery Place □ Charlotte Nature Museum□ Discovery Place KIDS-Huntersville

Which Summer Camp did you attend?_____________________________________________________________________________________________________________________________________________________

When did you attend Summer Camp? (please list dates) ________________________________________________________________________________________________________________________

What did you learn at Summer Camp? ____________________________________________________________________________________________________________________________________________________

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What was your favorite part of Summer Camp? _____________________________________________________________________________________________________________________________________________________

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